Healthcare Provider Details

I. General information

NPI: 1326040502
Provider Name (Legal Business Name): AVASCO MEDICAL SUPPLY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 04/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 EAST LOS ANGELES AVE. SUITE D
SIMI VALLEY CA
93065-7503
US

IV. Provider business mailing address

690 EAST LOS ANGELES AVE. SUITE D
SIMI VALLEY CA
93065-7503
US

V. Phone/Fax

Practice location:
  • Phone: 805-522-5333
  • Fax: 805-522-6333
Mailing address:
  • Phone: 805-522-5333
  • Fax: 805-522-6333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number100631
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number396218-03
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number396218-03
License Number StateCA

VIII. Authorized Official

Name: MR. RANDY ABABSEH
Title or Position: OWNER
Credential:
Phone: 805-522-5333